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Coordination of Care

I am working with a client who is taking an anti-depressant prescribed by a psychiatrist. She has begun to show symptoms of euphoria, rapid speech, and decreased need for sleep, which makes me wonder if she should be taking a mood stabilizer. She has signed a release giving permission for us to share information, so I’m wondering how to approach this issue in a phone call with the psychiatrist.

This is a good example of a case in which coordination of client care is very important. You probably see the client more often than the psychiatrist, so it’s understandable that you would see the emergence of these symptoms first. Communicating with your client’s prescribing psychiatrist will be beneficial to your treatment as well as possibly influencing the psychiatrist’s decisions. The topic of case management is covered in Chapter 12 of my book. Case management includes coordination of care and contacts you have with other professionals or family members.

The first issue that clinicians often face when contacting a psychiatrist is the difficulty of scheduling a time to talk. If s/he has an assistant, you may be able to schedule a time relatively easily, but if s/he works independently it is likely to be more challenging. I recommend leaving a message introducing yourself, stating you have a release you’re your mutual client giving permission for you to share information, and giving some times that you’re available. It is wise to include late afternoon or early evening times if possible, since s/he may return calls at the end of the day. If you don’t get a return call within two or three days, it’s fine to leave another message. There may be some back and forth exchange of messages before you’re able to speak in person, so be persistent.

Before you have the phone conversation, take some time to plan what you want to say and what you want to know. Separate the information you wish to provide from questions you have for the psychiatrist so you’re clear about your goals for the conversation. In this case, you want to share your observations about the client’s symptoms and you want to ask about the psychiatrist’s diagnosis and observations. There may be additional information that is helpful to exchange, but keep in mind the HIPAA requirement to share the minimum necessary information. Do not share details of the treatment or the client’s history that are not relevant for the psychiatrist’s prescribing decisions.

Before the call, notice your feelings in anticipation of the conversation. Some clinicians feel intimidated by psychiatrists, and this can lead to defensiveness or a lack of clarity. Work to prepare yourself for a collaborative, professional discussion. Since your primary goal is to let the psychiatrist know about the client’s recent symptoms, you might plan to start the conversation by saying “I have observed some changes in XX’s symptoms lately, and wanted to pass along that information. She has appeared euphoric and reports a decreased need for sleep. I’ve also seen some rapid speech that seems to indicate a flight of ideas. These changes have taken place over the last couple weeks, and I thought I should let you know.” It is best to refrain from making any suggestions about prescribing, since that is outside your scope of practice and may be off-putting to the psychiatrist. Stay with an objective report of what you have observed and what the client has reported. Keep your questions in mind, so you can ask those before the end of your conversation if they don’t come up naturally. The conversation may end with a plan to talk again in a specified period of time or with a more open ended agreement to check in as needed.

I recommend that you create a progress note documenting each time you have contact with another professional about your client. It provides evidence in the record that you have followed the standard of care, and it also gives you a reminder of the details of the conversation which may fade with time. A paragraph is usually long enough to summarize your conversation and any plan that resulted from it.

I also recommend that you talk with the client about your conversation with the psychiatrist when you meet for your next session so she feels included in the communication. A short summary reporting what you shared and what you heard is sufficient, followed by asking if there is anything else she’d like to know about your conversation.

You are now prepared to talk with the psychiatrist in a way that will benefit your client. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.